Fractures of the calcaneum.pptx. .

Fracture of calcaneum

1. Fractures of the calcaneu m Dr.Akshay (PT)

2. Introduction Calcaneus is the most often fractured tarsal bone . Function : Supports weight of the body. Acts as a springboard for locomotion. Structure : It has a thin cortical shell except at the posterior tuberosity . Two types of trabecular pattern are described . • Traction trabeculae: This radiates from the inferior cortex . • Compression trabeculae: Converge to support anterior and posterior facets .

3. Vital Angles In the lateral view of the radiograph, two angles are important : Böhler's angle: This is the angle between lines drawn from anterior articular process to the posterior tuberosity . The tuber angle is 25-40 °. Crucial angle of " Gissane ": The lateral process of talus is wedged in this angl . Axial compressive forces with talus acting as a bursting wedge will disrupt the subtalar joint. Restoration of the above two angles is the aim of the treatment.

4. Tuber joint angle ( Böhler's angle)

5. Gissane angle

6. Classification Essex- Lopresti's Classification This is the most accepted classification for fracture of calcaneum . It consists of extra-articular fractures (less common accounting for only 25 % of the cases) and intra-articular fractures, which is more common.

7. Essex- Lopresti's Classification Fracture anterior process Fracture tuberosity Medial process fracture Fracture sustentaculum Undisplaced fracture Tongue-shaped fractures Joint depression Comminuted fracture Extra-articular (25-30%) Intra-articular (70-75%)

8. Types of extra-articular fractures: (A) Sustentaculum tali fracture , (B) Medial process fracture, (C) Anterior process fracture , and (D) Tuberosity fracture

9. Varieties of intra-articular fractures: (A) Undisplaced fracture, (B) Tongue-shaped fracture, (C) Comminuted fracture

10. Classification Classification Based on CT Scan Findings (Intra-articular ) ( Crossby-Fitzgibban's Classification ) Type I : Undisplaced fracture. Type II : Displaced intra-articular fractures of the posterior facet (< 2 mm). Type III : Comminuted fractures.

11. EXTRA-ARTICULAR FRACTURES Mechanism of Injury Twisting forces cause many of the extra-articular fractures . Fall from height with landing on the heels causes vast majority of intra-articular fractures.

12. Facts Bilateral fractures are seen in 5-9 percent of cases. Ten percent cases have compression fracture of dorsal or lumbar vertebral bodies. Twenty-six percent are associated with other injuries of the lower limbs.

13. Clinical Features Patient complains of pain swelling, limp and painful restricted movements of the subtalar and the midfoot joints .

14. Radiography Plain X-rays of the foot with the following three views are recommended: Dorsoplantar or anteroposterior view Lateral view helps to study the crucial angle of Gissane Axial calcaneal view ( Haris view). CT scan is now emerging as the gold standard in evaluation of intra-articular calceneal fractures.

15. Radiographic views: (A) Dorsoplantar view , and (B) Lateral view

16. Treatment – Extra-articular Fracture Fracture of anterior process: Avulsion fracture—short leg cast . Compression fracture—should be reduced and fixed with K-wire or screw. Fracture of tuberosity : Undisplaced fracture—short leg cast. Displaced fracture—open reduction and internal fixation .

17. Treatment – Extra-articular Fracture Fracture medial calcaneal process: Undisplaced fracture—plaster cast. Displaced—open reduction with medial lateral compression and internal fixation. Fracture sustentaculum tali : Undisplaced—plaster cast. Displaced—open reduction and casting. Fracture of the body not involving the subtalar joint : Responds well to conservative treatment.

18. Short leg POP cast with walking heel for calcaneal fracture

19. INTRA-ARTICULAR FRACTURES These account for 60 percent of all tarsal injuries and 75 percent of all calcaneal fractures. Mechanism of Injury Fall from height: Lateral process of talus acts as a wedge and is forced through the Gissane's angle resulting in four fracture patterns: • Undisplaced. • Tongue shaped. • Joint depression. • Comminuted.

20. Clinical Features Pain and swelling of the heel, the patient is unable to bear weight, stand or walk, pain and difficulty during inversion and eversion of the heel.

21. Clinical Signs Swelling over the heel. Tenderness over the heel. Lateral heel compression test elicits pain Broadening of the heel (see Fig. 22.19B). Horseshoe swelling on either side the tendo Achilles . Distance between the heel and malleoli is reduced.

22. Heel compression test for diagnosing undisplaced or stress fracture of calcaneum

23. Radiography Plain X-rays of the foot as in extra-articular fractures CT scan is now emerging as the gold standard in evaluation of intra-articular calceneal fractures.

24. Treatment – Intra-articular Fracture Conservative The following are the basic methods of treatment: No reduction and early motion consists of: Elastocrepe bandage application. Foot elevation. Weight bearing at the end of 12 weeks. Closed reduction and fixation. Goals • Restore congruity of the subtalar joint. • Restore Böhler's angle. • Restore normal width of the calcaneum.

25. Omoto Technique of Calcaneal Fracture Reduction Under anesthesia (general or spinal), the patient is prone and knee is flexed to 90°. With the assistant supporting the thigh, the surgeon compresses the medial and lateral sides of the heel. Strong longitudinal traction is now applied along the direction of the leg. Varus or valgus force is now applied depending on the displacement. Lastly the calceneal tuberosity is manipulated in position . Compression bandage is finally applied.

26. Method of closed reduction of calcaneal fractures (Omoto technique)

27. Calcaneal Fracture Reduction Essex- Lopresti method of lifting the fragment with an axial percutaneous pin and retention with K-wires is done.

28. Essex- Lopresti method of reduction of calcaneal fractures: (A) Disimpaction, (B) Elevation

29. Surgery Severely comminuted and depressed fracture with subchondral defects requires open reduction and internal fixation with cancellous bone graft to fill the gap. Recently , for this purpose, alternatively , biocompatible and less reabsorbable nanocrystalline calcium phosphate cement called Bioban is being tried with successful results in some centers. Open reduction and internal fixation with plate and screws are difficult and are rarely adopted.

30. Complications Nonunion is rare due to the cancellous nature of the bone. Malunion is more common. Heel pain: The source of heel pain could be from: – Subtalar joint due to post-traumatic osteoarthritis. – Peroneal tendonitis due to stenosing tenovaginitis of the peroneal tendons . – Bone spurs due to malunion of fracture and disruption of fat pad of the heel. – Arthritis of calcaneocuboid joint is a major source of pain. – Nerve entrapment is rare. Medial or lateral plantar branches of posterior tibial nerve or sural nerve may be entrapped due to soft tissue scarring .

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